Cardionerds: A Cardiology Podcast

The following question refers to Section 7.2 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Cleveland Clinic internal medicine resident and CardioNerds Intern Akiva Rosenzveig, answered first by UPMC Harrisburg cardiology fellow and CardioNerds Academy House Faculty Leader Dr. Ahmed Ghoneem, and then by expert faculty Dr. Randall Starling. Dr. Starling is Professor of Medicine and an advanced heart failure and transplant cardiologist at the Cleveland Clinic where he was formerly the Section Head of Heart Failure, Vice Chairman of Cardiovascular Medicine, and member of the Cleveland Clinic Board of Governors. Dr. Starling is also Past President of the Heart Failure Society of America in 2018-2019. Dr. Staring was among the earliest CardioNerds faculty guests and has since been a valuable source of mentorship and inspiration. Dr. Starling’s sponsorship and support was instrumental in the origins of the CardioNerds Clinical Trials Program.  The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #27 Which of the following sentences regarding diuretics in the management of heart failure is correct? A In HF patients with minimal congestive symptoms, medical management with diuretics alone is sufficient to improve outcomes. B Prescribing a loop diuretic on discharge after a HF hospitalization may improve short term mortality and HF rehospitalization rates. C The combination of thiazide (or thiazide-like) diuretics with loop diuretics is preferred to higher doses of loop diuretics in patients with HF and congestive symptoms. D The maximum daily dose of furosemide is 300 mg. Answer #27 Explanation Choice B in correct. The guidelines give a Class 1 recommendation for diuretics in HF patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Recent data from the non-randomized OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed reduced 30-day all-cause mortality and hospitalizations for HF with diuretic use compared with no diuretic use after hospital discharge for HF. Choice A is incorrect. With the exception of mineralocorticoid receptor antagonists (MRAs), the effects of diuretics on morbidity and mortality are uncertain. As such, diuretics should not be used in isolation, but always combined with other GDMT for HF that reduce hospitalizations and prolong survival. Choice C is incorrect. The use of a thiazide or thiazide-like diuretic (e.g., metolazone) in combination with a loop diuretic inhibits compensatory distal tubular sodium reabsorption, leading to enhanced natriuresis. In a propensity-score matched analysis in patients with hospitalized HF, the addition of metolazone to loop diuretics was found to increase the risk for hypokalemia, hyponatremia, worsening renal function, and mortality, whereas use of higher doses of loop diuretics was not found to adversely affect survival. The guidelines recommend that the addition of a thiazide (e.g., metolazone) to treatment with a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class I, LOE B-NR).   Choice D is incorrect. The guidelines recommend a maximum total daily dose of 600mg of furosemide or 10mg of bumetanide or 200mg of torsemide. Main Takeaway In summary, diuretics are recommended in heart failure patients who have fluid retention to relieve congestion, improve symptoms, and prevent worsening heart failure. Maintenance diuretics on HF hospitalization discharge may help prevent recurrent HF hospitalizations. They should be used in combination with other GDMT to improve HF outcomes. Combining loop and thiazide diuretics may cause serious electrolyte abnormalities and should be reserved for patients who do not respond to moderate- or high-dose loop diuretics.   Guideline Loc. Section 7.2, Table 12   Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

Dr. Alexander Sasha Opotowsky, an expert in Eisenmenger Syndrome, discusses the diagnosis and management of this end-stage complication of congenital heart disease. Topics include pathophysiology, cyanosis-related complications, risks of pregnancy, treatment options, and a case study on SVC syndrome and ACHD physiology.

Dr. Cezar Iliescu discusses the spectrum of cardiovascular diseases encountered by interventional onco-cardiologists. Topics include endovascular therapies, special scenarios in critically ill cancer patients, adjustments to standard care for cancer patients with chronic thrombocytopenia, post-PCI care in cancer patients, treating aortic stenosis in cancer patients, and the passion for interventional cardiology.

The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks. Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center, where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology’s Cardiovascular Disease Prevention Leadership Council. The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #32 Mr. Daniel Collins is a 58-year-old man with hypertension, chronic kidney disease (CKD), and obesity who presents to your clinic for a routine physical examination. Vitals are as follows: BP 143/79 mmHg, HR 89 bpm, O2 99% on room air, weight 106 kg, BMI 34.5 kg/m2. Recent laboratory testing revealed: creatinine 1.24 mg/dL, total cholesterol 203 mg/dL, HDL 39 mg/dL, LDL 112 mg/dL, TG 262 mg/dL. His current medications include lisinopril and rosuvastatin. You recommend increasing the dose of lisinopril to treat uncontrolled hypertension. What additional step(s) are indicated at this visit? A Order urine albumin-to-creatinine ratio B Ask the patient how often they have been bothered by trouble falling or staying asleep, or sleeping too much C Perform depression screening D All of the above Answer #32 Explanation   The correct answer is D – all of the above. Answer A is correct. The ESC gives a Class I (LOE C) indication that all CKD patients, with or without diabetes, should undergo appropriate screening for ASCVD and kidney disease progression, including monitoring for changes in albuminuria. Cardiovascular disease is the leading cause of morbidity and death among patients with CKD. Even after adjusting for risk factors, including diabetes and hypertension, there is a linear increase in CV mortality with decreasing GFR below ~60-75 mm/min/1.73m2. Specific CKD-related risk factors include uremia-mediated inflammation, oxidative stress, and vascular calcification. Answer choice B is also correct. In patients with ASCVD, obesity, and hypertension, the ESC gives a Class I (LOE C) indication to regularly screen for non-restorative sleep by asking the question related to sleep quality as follows: “‘How often have you been bothered by trouble falling or staying asleep or sleeping too much?”. Additionally, if there are significant sleep problems that are not responding within four weeks to improving sleep hygiene, referral to a specialist is recommended (Class I, LOE C). However, despite the strong association of OSA with CVD, including hypertension, stroke, heart failure, CAD, and atrial fibrillation, treatment of OSA with CPAP has failed to improve hard CVD outcomes in patients with established CVD. Interventions that focus on risk factor modification, including reduction of obesity, alcohol intake, stress, and improvement of sleep hygiene, are important. Answer choice C is also correct. The ESC gives a Class I (LOE C) recommendation that mental health disorders with either significant functional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. All mental disorders are associated with the development of CVD and reduced life expectancy. Additionally, the onset of CVD is associated with an approximately 2-3x increased risk of mental health disorders compared to a healthy population. As such, screening for mental health disorders should be performed at every consultation (2-4x/year). Main Takeaway In addition to traditional ASCVD risk factors, other clinical conditions, including sleep apnea, CKD, and mental health conditions, are important to screen for and treat if present. Guideline Loc. Sections 3.4.1, 3.4.9, 3.4.10 CardioNerds Decipher the Guidelines – 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

The following question refers to Section 4.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Texas Tech University medical student and CardioNerds Academy Intern Dr. Adriana Mares, answered first by Rochester General Hospital cardiology fellow and Director of CardioNerds Journal Club Dr. Devesh Rai, and then by expert faculty Dr. Eldrin Lewis. Dr. Lewis is an Advanced Heart Failure and Transplant Cardiologist, Professor of Medicine and Chief of the Division of Cardiovascular Medicine at Stanford University.  The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #26 A 45-year-old man presents to cardiology clinic to establish care. He has had several months of progressive dyspnea on exertion while playing basketball. He also reports intermittent palpitations for the last month. Two weeks ago, he passed out while playing and attributed this to exertion and dehydration. He denies smoking and alcohol intake.   Family history is significant for sudden cardiac death in his father at the age of 50 years. Autopsy has shown a thick heart, but he is unaware of the exact diagnosis. He has two children, ages 12 and 15 years old, who are healthy.   Vitals signs are blood pressure of 124/84 mmHg, heart rate of 70 bpm, and normal respiratory rate. On auscultation, a systolic murmur is present at the left lower sternal border. A 12-lead ECG showed normal sinus rhythm with signs of LVH and associated repolarization abnormalities. Echocardiography reveals normal LV chamber volume, preserved LVEF, asymmetric septal hypertrophy with wall thickness up to 16mm, systolic anterior motion of the anterior mitral valve leaflet with 2+ eccentric posteriorly directed MR, and resting LVOT gradient of 30mmHg which increases to 60mmHg on Valsalva.   You discuss your concern for an inherited cardiomyopathy, namely hypertrophic cardiomyopathy. In addition to medical management of his symptoms and referral to electrophysiology for ICD evaluation, which of the following is appropriate at this time? A  Order blood work for genetic testing B  Referral for genetic counseling C  Cardiac MRI D  Coronary angiogram E  All of the above Answer #26 Explanation   The correct answer is B – referral for genetic counseling.  Several factors on clinical evaluation may indicate a possible underlying genetic cardiomyopathy. Clues may be found in: ·       Cardiac morphology – marked LV hypertrophy, LV noncompaction, RV thinning or fatty replacement on imaging or biopsy ·       12-lead ECG – abnormal high or low voltage or conduction, and repolarization, altered RV forces ·       Presence of arrhythmias – frequent NSVT or very frequent PVCs, sustained VT or VF, early onset AF, early onset conduction disease ·       Extracardiac features – skeletal myopathy, neuropathy, cutaneous stigmata, and other possible manifestations of specific syndromes In select patients with nonischemic cardiomyopathy, referral for genetic counseling and testing is reasonable to identify conditions that could guide treatment for patients and family members (Class 2a, LOE B-NR). In first-degree relatives of selected patients with genetic or inherited cardiomyopathies, genetic screening and counseling are recommended to detect cardiac disease and prompt consideration of treatments to decrease HF progression and sudden death (Class 1, LOE B-NR). No controlled studies have shown clinical benefits of genetic testing for cardiomyopathy, but genetic testing contributes to risk stratification and has implications for treatment, currently most often for decisions regarding defibrillators for primary prevention of sudden death and regarding exercise limitation for hypertrophic cardiomyopathy and the desmosomal variants. Consultation with a trained counselor before and after genetic testing helps patients to understand and weigh the implications of possible results for their own lives and those of family members, including possible discrimination on the basis of genetic information. Unless shown to be free of the genetic variant(s) implicated in the proband, first-degree relatives of affected probands should undergo periodic screening with echocardiography and electrocardiography. In this patient with likely hypertrophic cardiomyopathy, a family history of sudden cardiac death, recent unexplained syncope, and two children, a referral for genetic counseling is appropriate at this time. However, option A is incorrect because ordering genetic testing without meeting a trained counselor is not advised.  Main Takeaway  Patients with the possibility of genetic cardiomyopathies should be referred to trained genetic counselors before and after genetic testing to understand the implications of the testing and results. Guideline Loc.  Section 4.3, Table 7 Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

CardioNerds co-founder Dr. Dan Ambinder joins Dr. Abdelrhman Abumoawad, Dr. Leili Behrooz from the Boston University Vascular Medicine over hot chocolate in Boston. They discuss two interesting cases of lower extremity edema caused by May-Thurner syndrome. Dr. Naomi Hamburg (Professor of Vascular Medicine and Cards at BU/BMC) provides the ECPR for this episode. Audio editing by CardioNerds Academy Intern, Dr. Akiva Rosenzveig. “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” – Sir William Osler. CardioNerds thank the patients and their loved ones whose stories teach us the Art of Medicine and support our Mission to Democratize Cardiovascular Medicine. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Synopses – May-Thurner syndrome Case 1: A 34-year-old woman with HIV on HAART presenting with left leg swelling and non-healing new foot ulcer for 3 months. She works as a cashier. On exam, her BMI is 35 kg/m2 and there are intact pulses bilaterally. Her left leg has varicose veins in the territory of the great saphenous vein, hyperpigmentation, edema, and a foot ulcer. Her right leg appears normal. Venous Duplex ultrasonography showed chronic partially occlusive thrombus in the left common femoral and profunda femoral veins and decreased doppler respiratory variation on the left side. She was treated with debridement and compression therapy for ulcer healing. She was referred to vascular surgery and underwent contrast venography that demonstrated collateral circulation from the left lower extremity (LE) to the right lower extremity, and stenotic lesion at the left common iliac vein (LCIV). She was diagnosed with May-Thurner syndrome, and a venous stent was placed, and the patient was started on aspirin 81 mg daily for 6 months. Case 2: A 71-year-old man presented with left lower extremity pain and edema. He underwent a left lower extremity venous Duplex ultrasound that showed chronic thrombus in the left proximal to distal femoral vein and acute thrombus in the left popliteal vein and was started on anticoagulation (AC). The patient was also having palpitations and was found to have paroxysmal atrial fibrillation. He underwent pulmonary vein isolation during which it was noted that his LCIV was subtotally occluded. He underwent CT venogram which showed lumbosacral osteophytic compression of the LCIV known as bony May-Thurner syndrome. Given minimal symptoms, the decision was made not to pursue interventional options and to manage conservatively with AC which the patient needs regardless. Case Media – May-Thurner syndrome Pearls – May-Thurner syndrome An often under-recognized, but treatable cause of DVT is left common iliac vein compression known as May-Thurner syndrome. Most patients who have May-Thurner anatomy are asymptomatic. Only a minority of patients with the May-Thurner anatomy present with symptoms such as left leg edema/pain and DVT. Young women are at a higher risk of developing May-Thurner syndrome compared to men.  A high degree of suspicion is needed to investigate patients with unilateral left-sided leg symptoms and venous duplex features of May-Thurner syndrome. The diagnosis is made with non-invasive imaging including venous duplex, CT/MR venography, intravascular Ultrasound (IVUS), and catheter-based venography. Although IVUS is the gold standard for diagnosis, due to its invasive nature, it has been replaced by CT/MR imaging. Treatment includes anticoagulation if a thrombus is present. Most patients receive venous stenting at the obstructed site to prevent compression of the left common iliac vein. Some patients need catheter-directed thrombolysis prior to stent placement. Show Notes -May-Thurner syndrome What is May-Thurner syndrome? Classic May-Thurner syndrome is venous outflow obstruction due to external compression of the left common iliac vein by the right common iliac artery causing venous stasis which can lead to DVT. It is more common in women of reproductive age. Osteophytic/bony variant of May-Thurner Syndrome is when a prominent vertebral osteophyte compresses the iliac vein which is more common in older patients. For another fascinating case of May-Thurner Syndrome, presenting with CTEPH, enjoy CardioNerds episode 53. Case Report: CTEPH & May Thurner Syndrome – Temple University. What is the presentation of May-Thurner Syndrome and what are the risk factors? May-Thurner syndrome is often asymptomatic but may present with pain and swelling of the left leg with or without the presence of DVT. Some patients will develop signs of venous insufficiency such as varicose veins, pigmentations, and venous ulcers. Risk factors include scoliosis, female sex, use of oral contraceptives, and pregnancy. As demonstrated in CardioNerds episode #53, chronic thrombo-embolic pulmonary hypertension may be a long-term sequela. How do we diagnose May-Thurner Syndrome? Features suggestive of proximal obstruction in the venous Duplex for the initial assessment of DVT or venous insufficiency raise suspicion for May-Thurner syndrome. These features include loss of respiratory variation of the venous blood flow. IVUS is the gold standard to diagnose May-Thurner Syndrome and can also provide information regarding the chronicity of the thrombus, which could help decide management (for example, whether to perform thrombolysis of acute clot burden). CT/MR venography may have high sensitivity and specificity to detect iliac vein compression nearing 95%. It is also useful in ruling out other causes of iliac vein compression such as osteophyte compression of the iliac vein. How do you treat May-Thurner Syndrome? Management mainly focuses on addressing the patient’s symptoms. For patients with moderate to severe symptoms and significant venous stenosis, endovenous stenting is used rather than conservative management. There are a paucity of data to clarify the optimal antithrombotic regimen following venous stent placement. Practrice patterns varry significantly in terms of antiplatelet/anticoagulant choice and the duration of treatment. The presenct of complications such as DVT, venous stasis ulcer, etc should be managed as usual. References Mangla A, Hamad H. May-Thurner Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 30, 2022. https://www.ncbi.nlm.nih.gov/books/NBK554377/ Kaltenmeier CT, Erben Y, Indes J, et al. Systematic review of May-Thurner syndrome with emphasis on gender differences. J Vasc Surg Venous Lymphat Disord. 2018;6(3):399-407.e4. doi:10.1016/j.jvsv.2017.11.006    https://pubmed.ncbi.nlm.nih.gov/29290600/ Poyyamoli S, Mehta P, Cherian M, et al. May-Thurner syndrome. Cardiovasc Diagn Ther. 2021;11(5):1104-1111. doi:10.21037/cdt.2020.03.07 https://pubmed.ncbi.nlm.nih.gov/34815961/ Knuttinen MG, Naidu S, Oklu R, et al. May-Thurner: diagnosis and endovascular management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S159-S164. doi:10.21037/CDT.2017.10.14 https://cdt.amegroups.com/article/view/17529/18075

CardioNerds co-founder Dr. Amit Goyal and episode leads Dr. Jaya Kanduri (FIT Ambassador from Cornell University) and Dr. Jenna Skowronski (FIT Ambassador from UPMC) discuss Complications of acute myocardial infarction with expert faculty Dr. Jeffrey Geske. They discuss various complications of acute MI such as cardiogenic shock, bradyarrythmias, left ventricular outflow tract obstruction, ruptures (papillary muscle rupture, VSD, free wall rupture), and more. Show notes were drafted by Dr. Jaya Kanduri. Audio editing by CardioNerds Academy Intern, student doctor Tina Reddy. The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Beyond the Boards SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes – Complications of Acute Myocardial Infarction Sinus tachycardia is a “harbinger of doom”! The triad for RV infarction includes hypotension, elevated JVP, and clear lungs. These patients are preload dependent and may need fluid resuscitation despite having an elevated JVP. Bradyarrythmias in inferior MIs are frequently vagally mediated. The focus should be on medical management before committing to a temporary transvenous pacemaker, such as reperfusion, maintaining RV preload and inotropy, avoiding hypoxia, and considering RV-specific mechanical circulator support (MCS). Worsening hypotension with inotropic agents (e.g., dobutamine, epinephrine, dopamine, norepinephrine) after a large anterior-apical MI should raise suspicion for dynamic left ventricular outflow tract obstruction due to compensatory hyperdynamic basal segments. The myocardium after a late presentation MI is as “mushy as mashed potatoes”! Need to look out for papillary muscle rupture, VSD, and free wall rupture as potential complications. Papillary muscle rupture can occur with non-transmural infarcts, and often presents with flash pulmonary edema. VSDs will have a harsh systolic murmur and are less likely to present with pulmonary congestion. Free wall rupture can present as a PEA arrest. All of these complications require urgent confirmation on imaging and early involvement of surgical teams. Notes – Complications of Acute Myocardial Infarction How should we approach cardiogenic shock (CS) in acute myocardial infarction (AMI)? Only 10% of AMI patients present with CS, but CS accounts for up to 70-80% of mortality associated with AMI, usually due to extensive LV infarction with ensuing pump failure. Physical exam Sinus tachycardia is considered a “harbinger of doom”, when the body compensates for low cardiac output by ramping up the heart rate The presence of sinus tachycardia and low pulse and/or blood pressure in a patient with a large anterior MI should raise suspicion for cardiogenic shock Be wary of giving IV beta blockers in this situation as negative inotropes can precipitate cardiogenic shock (Commit Trial) When interpreting a patient’s blood pressure in the acute setting, it is helpful to know their baseline blood pressure and if they have a significant history of hypertension. Patients <75 years of age with CS have improved survival at 6 months and at 1 year with early revascularization (SHOCK trial) Mechanical circulatory support Intra-aortic balloon pump (IABP) No mortality benefit with IABP use in CS at 30 days and at 1 year (IABP-SHOCK II trial) ACC/AHA guidelines give IABP a class IIa recommendation for medically refractory AMI-CS in the USA, whereas the ESC guidelines give it a class III recommendation. Percutaneous left ventricular assist device (Impella) No difference in mortality between IABP or Impella use after 30 days or 6 months (IMPRESS trial) However, observational data like the Detroit & VAD registries show improvement in survival with Impella use in AMI-CS with the cost of excess complications (vascular injury, bleeding, etc) Upcoming trials (DanGer Shock and Recover IV) will hopefully have more promising data supporting the use of Impella in AMI-CS In the setting of discrepant guidelines, the decision for MCS should be multidisciplinary and based on clinical expertise.   For more on AMI-CS, enjoy CardioNerds #223. CCC: Approach to Acute Myocardial Infarction Cardiogenic Shock with Dr. Venu Menon How does RV infarction present? Physical exam RV infarct triad: hypotension, elevated JVP, clear lungs Hypotension precipitated by nitroglycerin administration highlights the preload dependent state of an infarcted RV GI symptoms (nausea and emesis) are common Patients may actually need fluids despite an elevated JVP because of an underfilled left ventricle EKG Consider a right sided leads (ST elevation in V1 and V4R are the most sensitive EKG markers of RV injury), but this should not delay emergent coronary angiography +/- PCI if suspicion for AMI is high Rhythm AV synchrony plays an important role in RV infarct given the dependence on preload If a patient loses AV synchrony due to heart block or atrial fibrillation, they can become more unstable due to a further drop in RV preload and overall cardiac output However, bradyarrythmias in inferior MIs are frequently vagally mediated, and therefore temporary Strategy for management of an inferior MI with RV infarct should be to optimize all other aspects hemodynamically before placing a temporary transvenous pacemaker (risk of RV perforation) Prompt reperfusion Maintain RV preload Inotropes Avoid hypoxia (potent pulmonary vasoconstriction, can increase RV afterload) MCS providing RV support (Protek-Duo, RP Impella, VA-ECMO) For more on RV-predominant cardiogenic shock, enjoy CardioNerds #239. CCC: Approach to RV Predominant Cardiogenic Shock with Dr. Ryan Tedford How does LVOT obstruction in a large anterior MI present? Hypotension with dobutamine or norepinephrine in a patient with an anterior MI and apical infarct, should raise suspicion for dynamic left ventricular outflow tract obstruction due to compensatory hyperdynamic basal walls Echocardiography is invaluable for diagnosis! Management Prompt reperfusion IV fluids (preload dependent) Beta blockers (eg: esmolol quick on, quick off) Phenylephrine (can improve BP by increasing afterload) Avoid positive inotropes (e.g., norepinephrine, epinephrine, dopamine, dobutamine, milrinone) Avoid IABP What are the different types of ruptures which may complicate a late-presentating MI? Papillary muscle rupture Posteromedial papillary more likely to be affected due to single coronary blood supply Papillary muscles are subendocardial so rupture can occur with non-transmural infarcts Presents with acute dyspnea from flash pulmonary edema and hypotension from drop in cardiac output Exam with new systolic murmur which may not be audible due to rapid equalization of pressures. For the same reason, Doppler may also underestimate the degree of MR. V wave from mitral regurgitation Ventricular septal rupture Risk factors: advanced age, female sex, first MI with lack of coronary collaterals Presents with hypotension, chest discomfort, dyspnea Exam with harsh systolic murmur with palpable thrill; pulmonary congestion is unusual unusual V wave from increased flow through the pulmonary circuit (but not high enough to cause flash pulmonary edema) Step up in RV saturation during right heart catheterization Inferobasal VSD with RCA infarcts (near the valves and conduction tissue and with more serpentine lesions, leading to worse outcomes) Apical VSD with LAD infarcts (can miss on TTE) Free wall rupture Risk factors: advanced age, female sex, first MI with lack of coronary collaterals Partial rupture may present as a vagal event that heralds the initial tear; TTE with new pericardial effusion should raise suspicion of an incomplete rupture Full rupture can present as PEA arrest with abysmally low survival May partially heal as a pseudo-aneurysm How do we manage rupture complications? For any of the three rupture scenarios (VSR, papillary muscle rupture, or free wall rupture), time is of the essence to confirm the site of rupture and to get the surgical team involved Can have abrupt, unexpected, unpredictable progression so need to bring in surgical expertise early Papillary muscle rupture will need mitral valve replacement For VSR closure, can pursue surgical versus percutaneous options depending on anatomical features of the lesion and patient characteristics Intervention is more challenging in inferobasal VSRs with higher operative mortality, but also less amenable to percutaneous closure (less likely to have appropriate rims for closure) If poor operative candidacy, more likely to opt for percutaneous options If size of defect large, would more likely lean towards surgery Can consider bridging with MCS if patient in CS (eg: IABP, Impella) as long as this will not delay the surgical intervention References Early intravenous then oral metoprolol in 45 852 patients with acute myocardial infarction: Randomised placebo-controlled trial. The Lancet. 2005;366(9497):1622-1632. doi:10.1016/s0140-6736(05)67661-1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67661-1/fulltext Dzavik V. Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: A report from the Shock Trial Registry. European Heart Journal. 2003;24(9):828-837. doi:10.1016/s0195-668x(02)00844-8. https://www.nejm.org/doi/full/10.1056/nejm199908263410901 Thiele H, Zeymer U, Neumann F-J, et al. Intraaortic balloon support for myocardial infarction with Cardiogenic shock. New England Journal of Medicine. 2012;367(14):1287-1296. doi:10.1056/nejmoa1208410. https://www.nejm.org/doi/full/10.1056/nejmoa1208410 Ouweneel DM, Eriksen E, Sjauw KD, et al. Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction. Journal of the American College of Cardiology. 2017;69(3):278-287. doi:10.1016/j.jacc.2016.10.022. https://www.jacc.org/doi/epdf/10.1016/j.jacc.2016.10.022 O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-425. https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6 Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35:2541-619. https://pubmed.ncbi.nlm.nih.gov/25173339/ Damluji AA, van Diepen S, Katz JN, et al. Mechanical complications of acute myocardial infarction: A scientific statement from the American Heart Association. Circulation. 2021;144(2). doi:10.1161/cir.0000000000000985. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000985

The following question refers to Figures 6-8 from Sections 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang. Dr. Yang is Professor of Medicine at the University of Washington where he is also the Medical Director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and as well as former Chair of the ACC Prevention of CVD Section.   The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #31 The 2021 ESC CV Prevention guidelines recommend a stepwise approach to risk stratification and treatment options. What is the first step in risk factor treatment regardless of past medical history, risk factors, or established ASCVD? A Initiate statin for goal LDL <100 mg/dl B Assess family history of premature CVD C Counsel on ketogenic diet D Stop smoking and lifestyle recommendations Answer #31 Explanation The correct answer is D – stop smoking and lifestyle recommendations. Smoking cessation and lifestyle modifications are recommended for everyone across the spectrum of ASCVD risk including for both primary and secondary prevention (Class 1). It is worth noting that many patients can move themselves towards a lower risk category without taking drugs just by stopping smoking. Option A is incorrect. While initiating statin therapy for goal LDL <100 mg/dL may be an appropriate treatment option for some patients, it is not the first step per the “stepwise approach” recommended in the ESC guidelines. Whether or not to initiate a statin depends on a multitude of factors including estimated 10-year CVD risk, age, comorbidities, established ASCVD, and patient preference. The first step for patients with established ASCVD includes LDL-C reduction to goal <70 mg/dL (class I) with intensification to a goal LDL-C <55mg/dL based on residual 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities, frailty, and patient preference.  Primary prevention of ASCVD first targets LDL-C goal <100 (class IIa) in appropriately selected patients. Option B is incorrect. While assessing family history of premature CVD should be part of an initial evaluation and certainly considered a risk enhancing factor, it is not a modifiable risk factor with regards to treatment. Option C is incorrect. A ketogenic diet is not endorsed nor recommended by ACC/AHA or ESC. Studies have shown the benefit of a stepwise approach to treatment intensification. Attainment of treatment goals is similar, side effects are fewer, and patient satisfaction is significantly greater with such an approach. It is not recommended to stop assessment of treatment goals after the first step. Main Takeaway A stepwise approach to treatment intensification is recommended. The first steps for all patients are to stop smoking and institute lifestyle recommendations. Guideline Loc. ·       3.2.3 Figures 6-8 CardioNerds Decipher the Guidelines – 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

The following question refers to Sections 6.1 and 7.3 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by Keck School of Medicine USC medical student & former CardioNerds Intern Hirsh Elhence, answered first by Greater Baltimore Medical Center medicine resident and CardioNerds Academy Fellow Dr. Alaa Diab, and then by expert faculty Dr. Mark Drazner. Dr. Drazner is an advanced heart failure and transplant cardiologist, Professor of Medicine, and Clinical Chief of Cardiology at UT Southwestern. He is the past President of the Heart Failure Society of America.  The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #25 A 50-year-old man with a history of type 2 diabetes mellitus, persistent atrial fibrillation, coronary artery disease with prior remote percutaneous coronary intervention, and ischemic cardiomyopathy with HFrEF (LVEF 38%) presents to your outpatient clinic. He denies dyspnea on exertion, orthopnea, bendopnea, paroxysmal nocturnal dyspnea, or peripheral edema. His heart rate is irregularly irregular at 112 beats per minute and blood pressure is 112/67 mmHg. Routine laboratory studies reveal a hemoglobin A1c of 7.7%. Which of the following medications should not be used to control this patient’s comorbidities? A Metoprolol succinate B Verapamil C Dapagliflozin D Pioglitizone E Both B and D Answer #25 Explanation The correct answer is E – both verapamil and pioglitazone should be avoided here. Both verapamil and pioglitizone are associated with harm in patients with LVEF < 50% (Class 3: Harm). Verapamil and diltiazem are non-dihydropyridine calcium channel blockers. These medications can cause negative inotropic effects through inhibition of calcium influx and may be harmful in this patient population. Pioglitizone belongs to a class of diabetic medications known as the thiazolidinediones. This class of medications may increase the risk of fluid retention, heart failure, and hospitalization in patients with LVEF of less than 50%. Metoprolol succinate, and other evidence-based beta blockers, have a Class 1 recommendation for patients with reduced ejection fraction ≤ 40% to prevent symptomatic heart failure and reduce mortality. It may additionally help with rate control in this patient with atrial fibrillation and rapid ventricular response. SGLT2 inhibitors including dapagliflozin have a Class I recommendation for patients with symptomatic chronic HFrEF to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes (Class 1, LOE A). They also have a Class I recommendation in patients with type 2 diabetes and either established CVD or at high cardiovascular risk to prevent hospitalization for HF (Class 1, LOE A). Our patient has asymptomatic, or pre-HF (Stage B) heart failure with poorly controlled diabetes, and so use of an SGLT2 inhibitor would be appropriate. Main Takeaway Non-dihydropyridine calcium channel blockers and thiozolidinediones both have Class 3 recommendations for harm in patients with reduced LV systolic dysfunction. Guideline Loc. Section 6.1 and 7.3   Decipher the Guidelines: 2022 Heart Failure Guidelines PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!

Stroke is a potentially devastating TAVR complication. In this episode, CardioNerds (Drs. Amit Goyal, Nikolaos Spilias, Ahmed Ghoneem, and Chelsea Amo-Tweneboah) discuss TAVR and stroke risk, stroke prevention strategies, and future directions with Dr. Samir Kapadia, Department chair and chief, Cardiovascular Medicine at Cleveland Clinic. They also discuss device innovation and randomized controlled trial implementation for testing device safety and efficacy. Audio editing by CardioNerds Academy Intern, Dr. Chelsea Amo Tweneboah. As an adjunct to this episode and for a deeper review of cerebral embolic protection devices, read “Cerebral Embolic Protection Devices: Current State of the Art” by Agrawal, Kapadia et al., in US Cardiology Review. Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Aortic Stenosis SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! References – TAVR and Stroke Leon MB, Smith CR, Mack M, et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. New England Journal of Medicine. 2010;363(17):1597-1607. Kapadia SR, Makkar R, Leon M, et al. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. New England Journal of Medicine. 2022;387(14):1253-1263. Kapadia SR, Kodali S, Makkar R, et al. Protection Against Cerebral Embolism During Transcatheter Aortic Valve Replacement. Journal of the American College of Cardiology. 2017;69(4):367-377. Khan MZ, Zahid S, Khan MU, et al. Use and outcomes of cerebral embolic protection for transcatheter aortic valve replacement: A US nationwide study. Catheter Cardiovasc Interv. 2021;98(5):959-968.